<span style="font-weight:bold;font-size:11px;"><?php echo __('Help for Work for Us') ?></span>
<hr />
<p><?php echo __("Employment-related messages should not be submitted here: this message goes to the application's developer, not the hiring manager or company. If you would like an answer from the developer, please provide an email address.") ?></p>
<form action="" id="contact_form" onsubmit="contact_form_submit(); return false;">
    <div class="clb">
        <label for="email"><?php echo __('Your Email') ?></label><input type="text" name="email" value="" />
        <p style="color:#808080;font-size:9px; margin-left : 113px"><?php echo __('Not required. The application developer will receive this email address. Only provide one if you need a response.') ?></p>
    </div>
    <input type="hidden" value="<?php echo $sf_user->getPageId() ?>" name="page_id"/>
    <div class="clb">
        <label for="issue"><?php echo __('Select a Category') ?></label><select name="issue">
          <option value="1" selected><?php echo __('Select a Category') ?></option>
          <option value="question"><?php echo __('Question about Application') ?></option>
          <option value="complaint"><?php echo __('Complaint about Application') ?></option>
          <option value="problem"><?php echo __('Report Problem with Application') ?></option>
          <option value="feedback"><?php echo __('Feedback to Application Developer') ?></option>
        </select>
    </div>
    <div class="clb">
        <label for="subject"><?php echo __('Subject') ?></label><input type="text" name="subject" value="" />
    </div>
    <div class="clb">
        <label for="message"><?php echo __('Message') ?></label><textarea name="message" rows="5"></textarea>
    </div>
</form>
